Pancreatic Tumors

Margo Shoup, MD

Associate Professor of Surgery

Loyola University Medical Center

Introduction

• 38,000 cases a year

• Risk factors

– Smoking

– Pancreatitis

• Real risk, but only 5% of

pancreatic cancer patients

Pancreatic Tumors

Genetics

• Tumor suppressor gene p53

• Mitogen activating gene k-ras

• COX-2

• VEGF

Pancreatic Tumors

Definitions

• Most common malignant pancreatic tumor is pancreatic ductal adenocarcinoma

• Difficult at diagnosis to determine etiology

– Periampullary tumor

• Pancreatic –65%

• Distal bile duct

• Ampulla

• Duodenum

• Islet cell

Pancreatic Tumors

Classification of pancreatic

tumors

• Cystic tumors

– Cystadenoma

• Serous

• Mucinous

• Intraductal papillary mucinous

• Solid and Pseudopapillary

Pancreatic Tumors

Surgical Options

• Enucleation

• Distal pancreatectomy with or without

splenectomy

• Central pancreatectomy

• Ampullectomy

• Pancreaticoduodenectomy

Pancreatic Tumors

Classification of pancreatic

tumors

• Malignant

– Adenocarcinoma

• Mucinous

• Adenosquamous

• Anaplastic

• Duodenal/ampullary/distal bile duct

– Cystadenocarcinoma• Mucinous

• Intraductal papillary

– Acinar

• Endocrine

Pancreatic Tumors

Tumor Markers

• CA 19-9

– Most commonly valued marker

– Not specific, high levels seen in benign disease

– Normalization following resection appears to be

associated with improved outcome

– Rising level after resection is a marker of relapse

– Levels > 1500 correlate with unresectable tumors

• Not cost effective for screening

Pancreatic Tumors

Clinical suspicion• Patients with pancreatic cancer commonly present

with advanced disease

– Head tumors – proximity to vascular structures

– Body and Tail – metastatic disease

• Symptoms are nonspecific

– Vague discomfort, dyspepsia, bloating

– Jaundice

– Weight loss, back pain usually a sign of advance disease

– Significant back pain 9% resectability vs minimal back pain 31% resectability

– New onset diabetes in patients over 60 should raise suspicion.

Pancreatic Tumors

Diagnosis

• History

– Weight loss

– Change in urine and stool

– Gastric outlet symptoms

– Back pain

• Physical

– Jaundice

– Cachectic

– Palpable mass

Pancreatic Tumors

Work up• CBC

• Liver function tests

• Hepatitis profile

• Hemolytic profile

• Ultrasound

• CT – identify mass, evaluate vessel involvement

• ERCP – double duct sign for head mass

• EUS – If not sure if pancreatitis vs tumor

Pancreatic Tumors

CT Findings

• Adenocarcinoma

– Irregular border

– Not hypervascular

– Pancreatic ductal dilatation

– Distal pancreatic atrophy

Pancreatic Tumors

Pancreatic adenocarcinoma

Pancreatic adenocarcinoma

CT Findings

• Neuroendocrine

– Well circumscribed

– Hypervascular

– No atrophy

• Cystic

– Appear fluid filled

– Well circumscribed

Pancreatic Tumors

Neuroendocrine Tumor

Intraductal papillary mucinous neoplasm

ERCP

• Not usually necessary

• Often performed if seen by Gastroenterologists

• Necessary if biliary stent is needed

• Double duct sign

– Strictured common bile duct and pancreatic duct

• Biopsy possible, not always needed

Pancreatic Tumors

Treatment Options

• Tissue diagnosis – NOT NECESSARY

– Unless surgery is not planned

• Potentially resectable tumors

– Laparoscopy to rule out metastatic disease

– Head tumors – pancreaticoduodenectomy

• Pancreatic head, distal common bile duct, duodenum, +/-antrum, gallbladder

• Pancreaticogastrostomy or jejunostomy, hepaticojejunostomy, gastrojejunostomy

– Body or Tail tumors – distal pancreatectomy with splenectomy

Pancreatic Tumors

Reconstruction Following Standard

Pancreaticoduodenectomy

Reconstruction Following Pylorus

Preserving Pancreaticoduodenectomy

Prognosis after surgery

• 1-3% perioperative mortality rate in the best

hands (30-day or same admisstion mortality)

– Previously was 20%

• 5 year survival

– Pancreas – 10-15%

– Bile Duct – 15-20%

– Duodenum – 50%

– Ampulla – 35%

– Islet cell – 40%

Pancreatic Tumors

Adjuvant therapy

• Options for chemotherapy and radiotherapy

– Inconclusive evidence that CRT improves survival

– GITSG trial

– 43 patients randomized to CRT vs. no CRT

– CRT had improved survival

• Neoadjuvant therapy

– Clinical trials

Predictors of outcome

• Nodal status

• Size (< 2cm)

• Margin status

Pancreatic Tumors

Complications

• Pancreatic duct leak/fistula

– Drain amylase level more than 3x serum

– 10-20%

• Biliary leak/Gastrojejunostomy leak

– Less common

• Delayed gastric emptying

• Pancreatitis

• Diabetes

• Dumping syndrome – exocrine insufficiency

Pancreatic Tumors

Follow-up

• If patients are asymptomatic follow with physical exam and history

• If patients start to become symptomatic, obtain CT

– Weight loss

– Anorexia

– Weakness

• Someone will order a CT sooner

– Patients peace of mind

• What to do with results if a recurrence is noted?

– Treatment with chemotherapy in the metastatic setting has not been shown to prolong life.

Pancreatic Tumors

Unresectable

• Majority of patients

• Locally advanced, not metastatic – May receive

chemotherapy with radiation.

– A small number of patients will respond enough to

become resectable.

– Median Survival 4-5 months if metastatic

– Median Survival 7-9 months if not metastatic

• Back pain can be palliated with celiac axis

blockade – alcohol injection

Pancreatic Tumors

Unresectable

• Metastatic disease – treatment options limited to

experimental medications and chemotherapy.

• Patients should have biliary stent placed by ERC

(Endoscopic retrograde cholangiogram)

– If unable to place stent due to technical difficulties,

should have operative biliary bypass

– Choledochojejunostomy, Hepaticojejunostomy,

Cholecystojejunostomy

• If considering CRT – need biopsy

Pancreatic Tumors

Unresectable Disease

• Biliary stents

– Plastic stent

• Best if patient considered for surgery

• 3- month longevity

• Easily removed

– Metal “Wallstent”

• Permanent

• Lasts 6 months to a year

• Difficult to remove surgically

Pancreatic Tumors

Defining Non-resectability

• Histologically confirmed hepatic, serosal,

peritoneal or omental metastasis

• Celiac or high portal node involvement

• Tumor extension outside of pancreas

• Extensive portal vein involvement by tumor or

invasion/encasement of celiac axis, hepatic

artery, or superior mesenteric artery.

Laparoscopic Staging

Laparoscopically Detected

Liver Metastasis

Laparoscopic Staging

Locally Advanced Tumors

• Considered candidates for chemoradiation if metastatic disease is not present.

• May be considered for subsequent surgical resection depending on the response to the chemoradiation.

• Patients with pancreatic adenocarcinoma metastatic to the liver or peritoneum are candidates for palliative chemotherapy, but not radiation.

Laparoscopic Staging

Locally Advanced Pancreatic Cancer

• Contemporary imaging modalities failed to

detect metastatic disease in 37% of patients.

• Patients considered for protocols including

radiation for locally advanced pancreatic

cancer should be staged laparoscopically

prior to initiating therapy.

Laparoscopic Staging

End of Life Issues

• Pancreatic cancer

– Almost as many people die each year from the disease as are diagnosed each year

– Pain/Back pain

• Biggest issue

• Control with celiac block, fentanyl patch

• Palliative radiation

– Gastric outlet obstruction – can be palliated by duodenal stent or gastric bypass (gastrojejunostomy)

• Patients with advanced disease should be referred to a hospice situation early

Pancreatic Tumors

End of Life

• Options for treatment vs no treatment

– Chemotherapy disappointing

• 5-FU, Gemcitabine, oxaliplatin

– Quality of Life

• Radiation

– Time consuming

– 5 days a week for 6 weeks

– Benefit not guaranteed

Pancreatic Tumors

End of Life

• Questions from patients –

– How much time do I have?

– Will you still be my doctor?

– How will I die?

– What should I do now?

Pancreatic Tumors

Case 1

• 52 year old man noted to have icteric sclera

and mild jaundice, no pain.

• H&P

• PE

• Labs

• Differential Diagnosis

Case 1

• Ultrasound

– Dilated intra- and extra-hepatic bile ducts, no

stones. Liver normal

– CT – 3 cm mass in head of pancreas. No liver

lesions. Dilated CBD and pancreatic duct

(Double duct sign)

– Now what?

Case 2

• 44 year old woman

• CT – pancreatic head mass

• Multiple liver lesions

• Now what?

Case 3

• 65 year old male had a screening CT scan at

the mall showing a 2 cm mass in the tail of

the pancreas.

• Asymptomatic

• Differential

• Work up

• Treatment

Recommendations for

Pancreatic Cancer• Laparoscopic

– Patients with resectable disease

– No evidence of gastric outlet obstruction

– Have biliary stent, or can receive biliary stent if needed

– Patients with locally advanced tumors, no metastasis on

imaging, considered for local therapy

• Open Exploration

– Failed biliary stent

– Gastric outlet obstruction

Laparoscopic Staging